Provider Demographics
NPI:1558550640
Name:CHIRO FITNESS XTREME LTD
Entity Type:Organization
Organization Name:CHIRO FITNESS XTREME LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:H
Authorized Official - Last Name:MOLCK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:309-788-8239
Mailing Address - Street 1:4014 BLACKHAWK ROAD
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201
Mailing Address - Country:US
Mailing Address - Phone:309-788-8239
Mailing Address - Fax:
Practice Address - Street 1:4014 BLACKHAWK ROAD
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201
Practice Address - Country:US
Practice Address - Phone:309-788-8239
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty